In August 1865 an eleven year old boy named James Greenlees was brought into Glasgow Royal Infirmary with a compound fracture of the leg after a cart went over it. Compound meant the bone had broken the skin, and in 1865 that was very often a death sentence. The standard treatment was amputation, and amputation carried a mortality of roughly one in two.
Joseph Lister set the bone and then did something new. He dressed the wound with lint soaked in carbolic acid and covered it to keep the air out. Six weeks later the boy walked out of the hospital with both legs.
Anaesthesia Made Things Worse
The usual account has surgery improving steadily through the nineteenth century. It did not. It got considerably more dangerous first, and the reason is that it got more comfortable.
Ether and chloroform arrived in the 1840s. Before them, an operation had to be over in seconds and a surgeon’s reputation rested on speed. Afterwards, a surgeon could take an hour, cut deeper, and operate on patients who would previously have been left alone.
The consequence was that many more wounds were being opened, in hospitals where the death rate from post operative infection ran between 40 and 60 percent in the worst institutions. Contemporary surgeons called the phenomenon hospitalism, and the four recognised forms were erysipelas, pyaemia, septicaemia and hospital gangrene.
Conditions supported it thoroughly. Surgeons operated in old frock coats stiff with the residue of previous operations, and a coat that was stiff enough to stand up on its own was a mark of experience. Instruments were wiped rather than cleaned. Silk ligatures were held in a buttonhole or between the teeth. The same sponge was used on several patients and rinsed between them.
The prevailing explanation was miasma, bad air rising from decomposition. It suggested ventilation, and ventilation did not help.
The Paper That Changed It
Lister was Regius Professor of Surgery at Glasgow and had been trying to understand wound inflammation for years, studying it under the microscope and getting nowhere with the theory available.
In 1864 a colleague drew his attention to Pasteur’s work on fermentation and putrefaction. Pasteur had shown that decay is not spontaneous but is caused by living organisms carried in the air, and that a sterilised broth stays clear indefinitely if those organisms are kept out.
Lister made the inference that nobody else had made: if putrefaction in a flask is caused by organisms from the air, then putrefaction in a wound is the same process, and the wound is a broth. Pasteur’s methods of exclusion, heat and filtration, cannot be applied to a living leg. A chemical that kills the organisms without destroying the tissue can.
He knew of carbolic acid because it was being used in Carlisle to treat sewage, where it reduced the smell and, it was reported, killed the parasites in the fields irrigated with the treated waste. He tried several preparations, worked out dilutions, and applied it systematically.
The Results and the Method
Lister published a series of cases in The Lancet in 1867 under the title on a new method of treating compound fracture, abscess and so forth, with observations on the conditions of suppuration. In his own wards, mortality after amputation fell from about 45 percent to about 15.
The system was more than a dressing. It included washing hands and instruments in carbolic solution, soaking the ligatures, cleaning the wound and the surrounding skin, and covering the wound with a dressing designed to keep out anything that might settle on it.
He also introduced the carbolic spray, a device that filled the operating theatre with a fine mist so that the air itself was treated. It made everyone’s eyes stream, cracked the skin of the surgeons’ hands, and it was the part of the system that Lister eventually abandoned, saying that he was ashamed of having been misled by the idea that the air was the main danger. The hands and instruments were.
Why the Same Idea Failed Twenty Years Earlier
Ignaz Semmelweis had shown in 1847 that washing hands in chlorinated lime nearly eliminated deaths in a Viennese maternity ward, and had been ignored, dismissed and eventually destroyed by the fight.
The difference between the two cases is instructive, because the medical facts are essentially the same.
- Lister had a mechanism. He could point to Pasteur and say what the enemy was and why the treatment worked. Semmelweis could only point to his own mortality tables
- Lister was inside the establishment. Regius Professor, son in law of his predecessor, later President of the Royal Society, and eventually the first surgeon raised to the peerage. Semmelweis was a Hungarian in a hostile Vienna
- Lister kept the argument technical. He answered objections with case series and demonstrations for nearly twenty years. Semmelweis eventually published open letters calling his opponents murderers
Lister acknowledged Semmelweis in later life, saying he had known nothing of his work at the time and that Semmelweis had anticipated the principle.
The Opposition
Adoption was slow in Britain and fast in Germany. The London surgical establishment was sceptical, partly because those who tried the method carelessly got poor results, and partly because accepting it meant accepting that surgeons had been causing the deaths.
The strongest technical criticism came from Lawson Tait, who pointed out correctly that carbolic acid damages tissue and can be absorbed to the point of poisoning, and who obtained excellent results by scrupulous cleanliness with soap, water and boiled instruments. He was arguing for asepsis rather than antisepsis, and he turned out to be pointing at the future.
That future arrived through Koch’s laboratory, where steam sterilisation was studied systematically. Ernst von Bergmann introduced the steam sterilisation of instruments and dressings in the 1880s. Rubber gloves entered surgery in 1890 at Johns Hopkins, when William Halsted had a pair made for his theatre nurse, later his wife, whose hands were being ruined by disinfectant. Masks, gowns and caps followed.
The distinction is worth keeping straight. Antisepsis kills the organisms in a wound that is already contaminated. Asepsis prevents them from arriving in the first place. Modern surgery is aseptic, and it descends from Lister’s principle rather than from his carbolic acid.
What It Made Possible
Before 1867 the abdomen, the chest and the skull were effectively closed to surgeons. Opening them meant infection and infection meant death, so operations were confined to the surface and the limbs.
Once wounds could be kept clean, the interior of the body became accessible. Appendectomy, gastric surgery, caesarean section as a survivable procedure for the mother, joint replacement and eventually transplantation all follow from it.
The remaining gap was what to do once an infection had established itself inside a patient, and that stayed unsolved for another seventy years until penicillin reached the clinic. Antisepsis stops the organisms getting in. Antibiotics deal with the ones that manage it anyway. Between them they account for most of the gap between surgical mortality then and now.
The Mouthwash
Lister operated on Queen Victoria in 1871, draining an abscess in her armpit, with the carbolic spray running. He later remarked that he was the only man who had ever stuck a knife into the Queen.
In 1879 an American company launched an antiseptic named Listerine, after him and without any involvement from him. It was marketed as a surgical antiseptic, then as a floor cleaner and a cure for gonorrhoea, and finally, in the 1920s, as a remedy for a condition its advertising agency largely invented under the name halitosis.
He would probably have preferred the other memorial. The surgical wards of the Glasgow Royal Infirmary in 1864 lost roughly half the patients who came into them for major operations. By the time Lister died in 1912 that had become a scandal rather than a fact of nature.
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